Hypertension is the most common cardiovascular condition in the world. Although the prevalence varies in different geographic regions, all countries face the challenge of developing effective control strategies. The single most pressing challenge in hypertension is increasing the rate of treatment and control. While considerable progress has been made in the US, much less has been accomplished in developing countries, where rates are 1-3 percent. Although the economic barriers are primary, additional health services research is also needed before strategies that are appropriate to poor countries can be developed. The overall goal of this project, therefore, is to develop the evidence base necessary to guide hypertension treatment and control programs in Africa. Three Specific Aims are proposed: (1) Conduct observational-analytic studies to assess the barriers to adherence. (2) Carry out interventions in a university outpatient clinic and in rural and urban community settings to define cost-effective procedures. Treatment arms will include various degrees of enhanced care (eg, free pills, appointment reminders, health education, case managers, transport). (3) Disseminate the results so that similar programs can be implemented and evaluated in other parts of Africa. Our interventions will address a single, two-part question: What pill taking rate and what control rate can be achieved using a simple drug regimen and various strategies to maximize adherence? We will monitor adherence by multiple strategies (eg, pill counts, random visits, urine tracer, etc). In addition we will focus on the care giver and determine the positive attributes of the health system that encourage patients to return for visits and take pills as prescribed. Finally, we will evaluate the overall treatment and control as the proportion of patients with BP <140/90. At the present time almost nothing is begin done to improve treatment of adult chronic disease in Africa, despite warnings of an "impending pandemic" of CVD. Great benefit could be obtained from applying therapies of proven efficacy. It is by no means self-evident, however, that drug treatment of asymptomatic conditions is practical in many parts of Africa using current methods. Whether our project yields a "positive" or "negative" result in relation to the main goal of identifying an effective clinical method, the outcome will have far-reaching implications for health care policy in that region.